Return to Work Advice for Physiotherapists

Original Editors - Fiona Chance-Larsen (returntoworkadvice.blogspot.ca)

Top Contributors - Evan Thomas, Amanda Ager and Claire Knott

Introduction

Returning to work after an injury is a very challenging, and sometimes scary, time for many patients. Physiotherapists are in a unique position compared to other health care providers to help patients not only recover from an injury through hands-on care and exercise, but also have the opportunity to engage, encourage, and educate them. But do enough therapists take advantage of this opportunity?

1. What are Physiotherapists Doing to Address Return to Work?

  • To date, advising patients about returning to work has primarily been the focus of physiotherapists who are members of ACPOHE (Association of Chartered Physiotherapists in Occupational Health and Ergonomics).
  • Moore reported that NHS outpatient physiotherapists do not routinely address work issues.[1]
  • The Work Foundation (UK) says health care professionals should consider the impact of musculoskeletal disorders on individuals ability to stay in and return to work.[2]


2. Why Should Physiotherapists be Involved?

  • Helping someone to remain in or return to work is an important part of the recovery process.[3]
  • Physiotherapists have a duty of care to discuss return to work strategies with their patients.[4]
  • There is strong evidence[5] regarding the impact of worklessness on health which includes:
    • Loss of fitness
    • Physical and mental deterioration
    • Increased risk of poor health (2-3 times greater)
    • Social Exclusion
    • Poverty
    • Psychological distress and depression (2-3 times greater)
    • Increased suicide and mortality rates


3. Is it within my Scope of Practice?

  • The CSP endorses consideration of work outcomes by all physiotherapists.[6]
  • Even simple efforts to identify and discuss work issues with patients can lead to better work outcomes.[7]
  • The Allied Health Federation has now produced an Advisory Fitness for Work Report,[8] which may be used by all physiotherapists.
  • Physiotherapists can help GPs tackle sickness absence.[9]


4. Work is Good for Physical and Mental Health

  • “Every time you stop someone falling out of work needlessly, you stop a reduction in the quality of human life, you help maintain a person’s sense of self-worth and dignity and you may help sustain family life and a stable community.”[10]
  • The evidence is strongly in support of the notion that work is good for physical and mental health. The converse also appears to be true, when remaining out of work.[11] The International Occupational Health guidelines for the management of low back pain, including those of the UK, are also in agreement that remaining at work or an early return to work, with modified duties if appropriate, should be both supported and encouraged. Early intervention is recommended in conjunction with addressing the misconception that the worker needs to be pain-free before returning to work.[12]
  • Helping someone to remain in or return to work is an important part of the recovery process.[3] The Department of Work and Pensions (DWP) maintain that not only are health professionals in a unique position to provide advice about work, but that crucially they also have a duty of care to discuss strategies for returning to work with their patients.[4]


5. What are the Occupational Health Guidelines for the Management of Low Back Pain?

  • For those having difficulty returning to work at 4-12 weeks:[12]
    • Exclude serious spinal pathology - red flags
    • Consider individual psychosocial factors - yellow flags
    • Consider work related psychosocial factors - blue flags
    • Focus on obstacles to recovery and return to work.
    • Anything about the person, workplace or circumstances that stand in the way of early return to work is an OBSTACLE!


6. What are Blue Flags?

  • Kendall, Linton and Main[13] coined the term “yellow flags“ to describe a set of identifiable psychosocial risk factors for prolonged disability, which included catastrophizing fears about pain or injury and unhelpful beliefs about recovery. More recently, these “yellow flags“ have been applied specifically to occupational contexts and have been termed ”blue flags”.[14]
  • Blue flags encapsulate an individual’s perceptions about work, which include:[15]
    • heavy physical demands
    • inability to modify work
    • stressful work demands
    • lack of workplace social support
    • job dissatisfaction
    • poor expectation of recovery
    • fear of re-injury
  • Although these elements are viewed as predictors of outcome, the evidence suggests they do not have equal measure. Much of the evidence from systematic reviews have pointed towards workers low expectations about recovery or returning to work as having the strongest predictive evidence.[16]


7. How can I Screen for Blue Flags?

  • Gray et al[16] undertook a systematic review of instruments for the assessment of blue flags in individuals with non-specific low back pain. They found that none of the instruments, which were predominately questionnaire based, could be recommended for use in clinical practice. The exception to this was the Obstacles to Return to Work Questionnaire (ORTWQ).[17] The ORTWQ is a valid measure of blue flags(1). Disadvantage: Time-consuming to complete(1) (it takes around 20 minutes).
  • The following subscales of the ORTWQ have been found to be predictive of absence from work,[16] and could be useful to guide a patient assessment regarding work outcomes:
    • perceptions of physical workload
    • social support at work
    • perceived prognosis of return to work
  • The following table is from Shaw et al[15] and outlines a pragmatic approach to identifying and responding to blue flags:

Workplace Factors in Back Disability.png

8. Physiotherapy Advice and Interventions

  • Dispel the myths about work and pain, by emphasizing the following aspects:
    • Back pain is often not caused directly by work, although some situations at work may exacerbate symptoms.
    • If managed appropriately, time off work is often not needed.
    • Work in a well-managed environment can support recovery.
    • You do not have to be 100% pain-free before return to work can be considered.
  • What else can I do?
    • Reassure patient that pain does not mean that work and activity are harmful.
    • Tell patients that staying active and at work helps people recover more quickly.
    • At 4-12 weeks provide the worker who has not returned to work with an active rehab program. This should consist of education, reassurance, exercise and pain management according to behavioural principles.
    • As a physiotherapist, give functional activities as exercises that simulate work demands.
    • Explore with the patient what they see as a reasonable plan for return to work.
  • Ask:
    • How confident are you about being able to return to work?
    • What do you think is preventing you from returning?
    • What might help you to return to work?
    • Outline a time frame and plan together for returning.
    • Agree upon realistic goals and expectations of health care
    • Encourage an incremental increase in activity levels.
    • Focus on what the patient is able to do, NOT what they can’t.
    • Consider modifications to work and /or phased return.
  • Shaw et al[18] presents a comprehensive plan for the management of work-related low back pain, specifically for physiotherapists. The table below from their article shows a client-centered problem-solving process to overcome workplace barriers:

Overcoming Workplace Barriers Cycle.png

9. Modified Work

  • Early return to work (RTW) can be helped by simple modifications to a person’s job.
  • Mostly this will be seen as a temporary measure.
  • Consider:
    • Altering physical demands by reducing heavy loads/limiting overreaching.
    • Reducing pace of work/take additional micro-breaks.
    • Enlist help of colleagues
    • Avoid static positioning/vary tasks/limit repetition.
    • Reduce working hours/days worked.
  • Shaw et al[18] present a comprehensive outline of how common methods of job modification can facilitate early return to work, as seen in the table below:

Job Modification for RTW.png

10. Sing from the Same Hymn Sheet

  • Successful RTW can only be achieved if all those involved in the process are communicating and expressing the same things. This includes the person, the GP, and the employer.
  • Conflicting advice can prolong sickness absence.
  • Try to be proactive and outline to the GP your recommendations for RTW.
  • Consider a direct discussion with the employer. Remember you will need your patient’s informed consent.

Additional Resources


References

  1. Moore (2011). Physios have been helping workers to avoid slipping from sick leave into long-term disability. CSP Frontline.
  2. Zheltoukhova K, O'Dea L, Bevan S. Taking the strain: The impact of Musculoskeletal Disorders on work and home life. Fit For Work UK. December 2012.
  3. 3.0 3.1 Dame Carol Black (2008). Working for a healthier tomorrow. Department of Work and Pensions. London, UK: TSO.
  4. 4.0 4.1 Department for Work and Pensions (2013). Advising Patients about Work.: An evidence-based approach for General Practitioners and other healthcare professionals. London, UK: TSO.
  5. http://www.healthyworkinguk.co.uk/
  6. Eaton L (2013). Business as usual. CSP Frontline.
  7. Costa-Black KM, Loisel P, Anema JR, Pransky G. Back pain and work. Best Pract Res Clin Rheumatol, 2010. 24(2): 227-40.
  8. Allied Health Professions Advisory. Fitness for Work Report.
  9. Browning S. How physios can help GPs tackle sickness absence. Fit UK Blog (May 2013).
  10. Dame Carol Black. ABC Radio National Life Matters Podcast (May 2012).
  11. Waddell G, Burton AK (2006). Is work good for your health and well-being? London, UK: TSO.
  12. 12.0 12.1 Staal J, Hlobil H, van Tulder MW, Waddell G, Burton A, Koes B, van Mechelen W (2003). Occupational health guidelines for the management of low back pain: an international comparison. Occupational Environmental Medicine, 60(9): 618-626.
  13. Kendall et al (1997) Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long-term disability and work loss, Wellington: NZ. Accident Rehabilitation and Compensation Insurance Corporation of New Zealand and the National Health Committee.
  14. Main CJ, Sullivan MJ, Watson PJ (2008). Pain Management: Practical Applications of the Biopsychosocial Perspective in Clinical and Occupational Settings. London, UK: Churchill Livingstone.
  15. 15.0 15.1 Shaw WS, van der Windt DA, Main CJ, Loisel P, Linton SJ. Early patient screening and intervention to address individual-level occupational factors (“Blue Flags”) in back disability.Journal of Occupational Rehabilitation, 2009; 19(1): 64-80.
  16. 16.0 16.1 16.2 Gray H, Adefolarin AT, Howe TE. A systematic review of instruments for the assessment of work-related psychosocial factors (Blue Flags) in individuals with non-specific low back pain. Manual Therapy, 2011; 16(6): 531-543.
  17. Marhold C, Linton SJ, Melin L. Identification of obstacles for chronic pain patients to return to work: Evaluation of a questionnaire. Journal of Occupational Rehabilitation, 2002; 12(2): 65-75.
  18. 18.0 18.1 Shaw WS, Main CJ, Johnston V. Addressing occupational factors in the management of low back pain: implications for physical therapist practice. Phys Ther, 2011; 91(5): 777-89.